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EENT > External and middle ear > Flashcards

External and middle ear Flashcards

1
Q

4 types of OE

A
  1. Acute Otitis Externa (AOE)
  2. Chronic Otitis Externa (COE)
  3. Malignant or Necrotizing Otitis Externa
  4. Herpes Zoster Oticus (Ramsey-Hunt)
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2
Q

2 types of AOE

A
  1. Diffuse - “Swimmer’s Ear”
    - Pseudomonas MC
  2. Localized - Furunculosis
    - Infection of a hair follicle
    - Staph aureus typically
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3
Q

2 types of COE

A
  1. Otomycosis
    - Infection with a fungal species
  2. Non-infective
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4
Q

pt presents with
Itching
Severe pain
Conductive hearing loss
Feeling of fullness or pressure
they’ve been swimming a lot this summer
what could it be?

A

AOE - diffuse

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5
Q

during an otoscope exam you see
Purulent discharge
Pain with palpation of tragus or traction of auricle (classic sign)
Swollen, red canal
Moist debris in canal
TM difficult to visualize
what could it be?

A

AOE - diffuse

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6
Q

tx for AOE - diffuse

A
  1. Thoroughly clean ear canal to remove debris
    - Hypertonic saline solution
  2. Topical antibiotics
    - Ofloxacin (Floxin) otic soln or Ciprofloxacin
    - Cortisporin Otic soln or susp (Neomycin, Polymyxin B, Hydrocortisone)
    - Cipro HC or CiproDex otic soln
    - 5 drops BID or TID
  3. Pain relief
    - Avoid promoting factors
    - cx if severe, or no resolution
  4. Ear wick
    - Placed in swollen canal
    - Helps distribute medicine and keep medicine in canal
    - Expands as its moistened
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7
Q

Tx for severe or immunocompromised AOE - diffuse

A

Systemic antibiotic and / or steroids
Ciprofloxacin 500mg BID for 1 week

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8
Q

infection of hair follicle is what kind of AOE?

A

Furunculosis
lateral ⅓ of canal

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9
Q

MC pathogen that causes furunculosis

A

staph aureus

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10
Q

tx for AOE - furunculosis

A
  1. Oral Dicloxacillin or Cephalexin (Keflex)
  2. I&D if needed
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11
Q

Fungal infection of the ear canal
Can arise from previous abx in ear/hot, humid climates

A

Chronic Otitis Externa - Otomycosis

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12
Q

Ear itching, discomfort, discharge, foreign body sensation in ear
Deep seated itching is most troublesome
is associated with what condition

A

Chronic Otitis Externa - Otomycosis

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13
Q

Edema less severe than bacterial
May resemble mold growing on spoiled food
associated with soft, white, sebaceous-like material that may fill ear canal
what condition is this?

A

Otomycosis

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14
Q

tx for Otomycosis

A

Cleaning of canal
Cotrimazole 1% solution BID 10-14 days

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15
Q

non-infective COE is repeated local irritation from what conditions?

A
  1. Seborrheic Dermatitis
  2. Psoriasis
  3. Contact Dermatitis
    - Shampoo, cosmetics, ototopical medications
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16
Q

pt seen with a Canal that is red, scaly and dry
they have a hx of seborrheic dermatitis
what condition could their ear be having?

A

COE - noninfective

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17
Q

tx for Chronic Otitis Externa - Non-infective

A

Topical Hydrocortisone cream/otic drops

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18
Q

Potentially life-threatening
Infections spreads from skin to bone and marrow spaces of the skull base

A

COE - Malignant/Necrotizing

Misnomer= it is not neoplastic process

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19
Q

COE - Malignant/Necrotizing MC causative organism

A

pseudomonas

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20
Q

Malignant/Necrotizing COE is MC in what kind of pts?

A

Elderly patients with Diabetes Mellitus
Immunocompromised patients

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21
Q

for the past several months, your pt has experiencing a temporal HA, and has been smelling a foul odor from their ear
you exam and see Severe, deep seated otalgia out of proportion to examination findings
what could be this condition?

A

COE- Malignant/Necrotizing

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22
Q

Granulation tissue at the bony cartilaginous junction of the ear canal floor
is the hallmark finding for what?

A

COE - malignant/necrotizing

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23
Q

complications with Chronic Otitis Externa - Malignant/Necrotizing

A
  1. Spread to base of skull - osteomyelitis
  2. Spread to meninges and brain
  3. CN involvement - cranial nerve palsy
  4. Thrombosis of sigmoid sinus
  5. High mortality rate
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24
Q

how do you diagnose COE - malignant/necrotizing

A
  1. CT scan
    - Determine extent of disease via demonstration of osseous erosion
  2. BX of granulation tissue
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25
Q

tx for COE - malignant/necrotizing

A
  1. Aggressive glycemic control
    - IV and oral Antibiotics 6 - 8 weeks typically required:
    - Ciprofloxacin 200-400mg BID 1st line
    - Piperacillin, Cefepime (Maxipime)
    - Treat until clinical improvement seen
  2. Selected patients may be graduated to oral ciprofloxacin
    - Ciprofloxacin 500 - 1000 mg BID
    - Treat until gallium (nuclear) scan is clear of inflammation (generally 6-8 weeks)
  3. Surgical debridement
    - In severe, refractory cases only, not usually needed
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26
Q

Herpes zoster infection of geniculate ganglion
Sensory ganglion of facial nerve

A

COE - Herpes Zoster Oticus
Ramsay Hunt Syndrome

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27
Q

Unilateral facial nerve (CN VII) palsy, severe otalgia, vesicular eruption on the face
Altered taste and tongue lesions sometimes noted
May be indistinguishable from Bell’s palsy if paralysis precedes rash

A

Chronic Otitis Externa - Herpes Zoster Oticus
Ramsay Hunt Syndrome

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28
Q

tx for Chronic Otitis Externa - Herpes Zoster Oticus

A

Steroids and antivirals
Prednisone and Famciclovir (Famvir) or Valacyclovir (Valtrex)

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29
Q

what is the protective secretion produced by outer portion of ear canal

A

cerumen

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30
Q

how is the ear canal self-cleaning

A

Outer layer of skin sheds
Wax goes with it

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31
Q

what causes cerumen impaction?

A

self-induced
Recommended hygiene only consists of cleaning external opening with a washcloth over the index finger

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32
Q

indications for cerumen impaction removal

A

Difficulty examining the TM
Otitis externa
Work-up for hearing loss
Suspected ear canal pathology
Patient request

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33
Q

contraindications for cerumen impaction removal

A

Presence or history of perforated TM
Previous pain on irrigation
Previous surgery of the middle ear or mastoidectomy
Uncooperative patient
Very hard cerumen

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34
Q

techniques for cerumen impaction removal

A
  1. Irrigation
    - Water at body temp to avoid a vestibular caloric response
    - Direct stream at ear canal adjacent to cerumen plug
    - Dry canal with hair dryer on low power or rubbing alcohol - Reduces likelihood of external otitis
  2. Mechanical removal
    - Ear curette
  3. Microsuction
  4. In-home therapy
    - 3% hydrogen peroxide
    - Detergent ear drops OTC - Debrox, Cerumenex
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35
Q

Ear FB is MC in who?

A

children

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36
Q

removal of ear FB?

A
  1. Irrigation
    - Avoid if organic foreign body that can expand when moistened (think beans or insects)
  2. Mechanical
    - Alligator forceps or ear curette
  3. Living insects
    - Immobilize first with lidocaine
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37
Q

Collection of blood under the perichondria
Connective tissue found covering the surfaces of cartilages

A

auricle hematoma

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38
Q

auricle hematoma results from ?

A

direct trauma to the anterior auricle

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39
Q

if untreated auricle hematoma can progress to what?

A

“Cauliflower ear” or “Wrestler’s Ear”

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40
Q

tx for auricle hematoma

A
  1. Within 7 days, otherwise refer
    - Prevents significant cosmetic deformity
  2. Lidocaine 1%: auricle block
  3. I&D
  4. Irrigate pocket with NS
  5. Compression dressing x 7 d
  6. Re-examine every 24 hrs
  7. Avoid NSAIDS
  8. Antibiotic prophylaxis +/-
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41
Q

goal tx for auricle hematoma

A

Evacuate subperichondrial blood
Prevent its reaccumulation

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42
Q

goal tx for auricular lac

A

Cover exposed cartilage
Minimize wound hematoma

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43
Q

what examinations do you do for auricular lacs

A

TM, External auditory canal
Facial nerve
Basilar skull fracture
Hearing deficit

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44
Q

management for auricular lac

A
  1. Tetanus vaccine if indicated
  2. Antibiotics if:
    - Contaminated wound
    - Bite injuries
    - Signs of inflammation
  3. Primary closure is preferred
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45
Q

technique for primary closure of an ear lac

A
  1. Anesthesia
  2. Debridement
  3. Copious Irrigation
  4. Suture
  5. Packing
    - Xeroform strips into ear crevices
    — Petrolatum occlusive dressing
  6. Compression dressing
  7. Recheck 24 hours
  8. Sutures out in 4 - 5 days
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46
Q

when to refer auricular lac

A

Refer to plastic surgery
1. Large skin avulsions (5 mm or >)
2. Severe crush injuries
3. Complete or near complete avulsion
4. Auricular hematoma
5. Large cartilage defect (> 5 mm)
6. Wounds that require removal of > 5 mm tissue
7. Involvement of auditory canal
8. Tissue devitalization

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47
Q

Swollen, erythematous, hot external ear lobule from Minor trauma, insect bite, or ear piercing

A

Auricular Cellulitis

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48
Q

tx for Auricular Cellulitis

A
  1. Oral abx
    - Cephalexin
    - TM-SX (MRSA)
    - Clinda (MRSA)
  2. IV abx - severe
    - vancomycin
    — Tachycardia
    — Rapid progression of erythema
    — Progression despite oral abx
    — Systemic toxicity (fever >100.5)
  3. Warm compresses
  4. NSAIDS for pain management
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49
Q

Infection of the perichondrium of the auricular cartilage where the lobe is less involved
Due to local trauma, surgery, burns

A

Perichondritis

50
Q

what causes ear deformity in perichondritis

A

interruption to blood supply to cartilage

51
Q

perichondiritis can rapidly progress to what other serious condition

A

necrosis of cartilage

52
Q

MC causative pathogen of perichondritis

A

pseudomonas
staph aureus

53
Q

tx for perichondritis

A
  1. Want to start within 5 days
    - Risks hospitalization and deformity
  2. Oral or IV Ciprofloxacin
  3. I&D
54
Q

Fluid in the middle ear
is what condition

A

Middle ear effusion

54
Q

Fluid in the middle ear
is what condition

A

Middle ear effusion

55
Q

Acute infection of the middle ear fluid
is what condition

A

Acute otitis media

56
Q

Middle ear fluid that is NOT infected
Also called “serous otitis media”
Frequently precedes OM or follows its resolution

A

Otitis media with effusion

57
Q

what do you document when describing the TM?

A
  1. Comment on color, translucency (clearness) and if intact.
  2. Commenting on pertinent negatives is also appropriate - ie - No erythema, no bulging, no retraction, no drainage.
  3. If mobility is assessed, then also comment on mobility (ie - TM clear, intact, and mobile).
58
Q

An acute, suppurative, infectious process marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the inner ear space

A

Acute Otitis Media

59
Q

AOM is MC in who?

A
  1. sick children
    - 60 - 80% of children have at least one episode by 1 year old
    - 80 - 90% by 2 - 3 years old
  2. Most prevalent in infancy
60
Q

Most common reason for antibiotic use

61
Q

what can reduce AOM incidence

A

pneumococcal vax

62
Q

risk factors for AOM

A
  1. Age
    - Peaks between 6 - 24 months
  2. Family History
  3. Daycare
  4. Lack of breastfeeding
  5. Tobacco use
  6. Seasonal
  7. Altered host defenses and underlying disease
  8. Pacifier use
63
Q

what condition generally always precedes AOM?

64
Q

what preserves middle ear conditions through clearance of middle ear fluid, ventilation, and protection from nasopharyngeal reflux

A

Eustachian tube

65
Q

how does an Impaired function of the Eustachian tube lead to AOM?

A
  1. retention and suppuration of retained secretions
  2. Dysfunction induces a negative pressure in the middle ear space
    - Negative pressure followed by accumulation of secretions produced by the middle ear mucosa
  3. Viruses and bacteria that colonize the upper respiratory tract enter the middle ear
66
Q

MC pathogenic causes of AOM

A
  1. Streptococcus pneumonia MC
  2. Haemophilus influenzae
    - More with bilateral otitis media
    - Conjunctivitis
  3. Moraxella Catarrhalis
    - 10% of cases
67
Q

which bacterial cause of AOM is
More common in older children
More local complication

A

Group A streptococcus

68
Q

which bacterial cause of AOM causes Acute otorrhea in children with tympanostomy tubes

A

Staphylococcus

69
Q

which bacterial cause of AOM is responsible for AOM in the first months of life?

70
Q

which bacterial cause of AOM is responsible for chronic, suppurative OM

A

pseudomonas

71
Q

which bacterial cause of AOM is MC in infants younger than 2 wks

72
Q

what viruses can cause AOM

A
  1. Respiratory Syncytial Virus (RSV)
  2. Picornaviruses
    - Rhinovirus
    - Enterovirus
  3. Coronaviruses
  4. Influenza
  5. Adenoviruses
  6. Human Metapneumovirus
73
Q

clinical s/s of AOM

A
  1. Ear pain
    - MC but not always present
  2. Non-specific signs and symptoms
    - Cough, congestion, Fever, irritability, HA, anorexia, N/V/D, ear tugging, decreased hearing
  3. Bulging of TM
  4. Mobility of TM
    - Poor mobility when pneumatic pressure is applied using a pneumatic otoscope
  5. erythema of TM or otalgia
74
Q

what distinguishes AOM from OM with effusion

A

bulging of TM in AOM

75
Q

middle ear effusion would present how?

A

TM suppurative opacity
Decreased or absent TM mobility
- Pneumatic otoscopy
- Tympanometry
Otorrhea

76
Q

fever, otalgia, decreased hearing, tinnitus, vertigo, erythematous TM
is seen in what condition

A

middle ear inflammation

77
Q

tx for mild-moderate AOM

A
  1. Initial therapy
    - Amoxicillin 875mg BID
    - Cefdinir (Omnicef) 300mg BID
    - Cefuroxime (Ceftin) 500mg BID
    - Azithromycin (Zithromax) 500 PO Day 1, then 250 QD PO on Days 2-5
    — Lack activity against most H. flu and ⅓ of pneumococcal isolates
  2. exposure to abx within 30 d / tx failure after 72 hrs
    - Amoxicillin plus Clavulanate 875mg (Augmentin ES or XR) PO in divided doses BID,
    - Cefdinir (Omnicef) 300mg BID
    - Ceftriaxone (Rocephin) 1g-2g IM daily for 3 days, OR
    - Clinda 30-40 mg/kg/d PO in divided doses TID
78
Q

if the pt is allergic to PCN what else could you tx for AOM

A
  1. Cephalosporins - recommended to those who do not have anaphylaxis
    - Cefdinir
    - Ceftriaxone
  2. Zithromax or doxy - recommended for immediate PCN hypersensitivity, such as anaphylaxis.
79
Q

tx for severe AOM

A
  1. Initial therapy or with associated bacterial conjunctivitis (Likely H. Influenza)
    - Augmentin ES
    - Ceftriaxone (Rocephin)
  2. exposure to abx within 30 d / tx failure
    - Ceftriaxone (Rocephin)
    - Clindamycin
    - Consider tympanocentesis

Duration of all meds
- 10 d - patients < 6 y/o and/or with severe disease, TM perforation or recurrent AOM
- 5 - 7 d (with consideration of observation only in previously healthy individuals with mild disease) - ≥ 6 y/o

Failure to improve and/or clinical worsening in 48 - 72 hours needs re-evaluated

80
Q

when would you need referral for AOM

A

for ENT - Tympanostomy Tubes
1. 3 or > AOM within 6 months
2. 4 or > AOM within 12 months
3. Unresponsive to pharmacological treatment regime

81
Q

complications for AOM

A
  1. Hearing loss
  2. Balance and motor problems
  3. TM perforation
  4. Tympanosclerosis
  5. Chronic suppurative OM
  6. Cholesteatoma
  7. Ossicular fixation
  8. Extension of suppurative process to adjacent structures
    - Mastoiditis
  9. Intracranial complications
    - Meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis
82
Q

prevention of AOM

A
  1. Encourage breastfeeding
    - IgA is secreted through breastmilk
    - Offers protective qualities
  2. Upright for bottle feedings
  3. Avoid passive smoke exposure
  4. Limit exposure to groups of children
  5. Careful hand washing
  6. Avoid pacifier use >10 months old
    - Constant sucking action exacerbates eustachian tube dysfunction
    - Causes auditory tubes to become abnormally open
    — Allows secretions from the throat to seep into middle ear
    — This transmission of bacteria in the secretions can lead to middle ear infections
  7. Immunizations
83
Q

Otitis media complications

A
  1. Bullous Myringitis
  2. TM rupture
  3. Tympanosclerosis
  4. Chronic Suppurative OM
  5. Chronic otitis media
  6. Cholesteatoma
  7. Mastoiditis
84
Q

Associated with AOM with bullae present on the TM

A

Bullous Myringitis

85
Q

tx for Bullous Myringitis

A
  1. same as AOM
  2. may need atypical coverage
    - Mycoplasma
    Zithromax
86
Q

Rupture accompanied by sudden decrease in pain, followed by otorrhea

A

Tympanic Membrane Rupture

87
Q

tx TM rupture

A
  1. Audiogram to check hearing
    - Now and repeat in 3 months
  2. Oral and Topical antibiotics
    - Oral same as AOM - Amoxicillin, Augmentin, Cefdinir
    - Low ototoxicity topical Ab - Ofloxacin, Ciprodex
  3. Earplugs - Swimming and bath
  4. Spontaneous resolution
    - Weeks to months
  5. Tympanoplasty if no resolution
88
Q

When describing a perforation, you must describe:

A
  1. Location (o’clock)
  2. Give idea of size of perforation
  3. Also comment if there are any signs of infection
89
Q

Scar on the TM

A

Tympanosclerosis

90
Q

Consequence of recurrent OM
Presence of perforation of the TM with chronic purulent drainage from the middle ear for >6 weeks (otorrhea)

A

Chronic Suppurative OM

91
Q

what can exacerbate chronic suppurative OM?

A

URI or after swimming

92
Q

what bacterial causative agents are responsible for Chronic otitis media

A
  1. Pseudomonas
  2. Proteus
  3. S aureus
  4. mixed anaerobic infections
93
Q

tx for chronic OM

A
  1. Meds
    - Topical Ab: Ofloxacin/Cipro + dexamethasone for exacerbations
    - Oral: Ciprofloxacin 500 mg BID X 1-6 weeks
  2. Removal of debris, use earplugs to protect against water exposure
  3. Definitive management = surgical
94
Q

TM surgical repair may be accomplished with what muscle?

A

temporalis muscle fascia

95
Q

Abnormal growth of squamous epithelium in middle ear and mastoid
May enlarge to surround and destroy the ossicles

A

Cholesteatoma

96
Q

what causes Cholesteatoma

A
  1. Due to chronic negative pressure in the middle ear
  2. MC - Prolonged eustachian tube dysfunction
97
Q

clinical findings of cholesteatoma

A

Typically erode bone
1. Deep retraction pockets
2. White mass behind the TM
3. Focal granulation at the TM periphery
4. Can become chronically infected
5. Ear drainage for >2 weeks despite treatment
6. Hearing loss - conduction - due to ossicular erosion

98
Q

tx for cholesteatoma

A

Refer - surgery
Surgical marsupialization or removal

99
Q

Occurs after several weeks of untreated or inadequately treated OM
Pus filling the air cells

A

Mastoiditis
Mastoid air cells connect with middle ear
Erosion of the surrounding bone
Formation of abscess-like cavities

100
Q

fluid found in the middle ear is almost always with fluid in where?

101
Q

pt presents with
Pain, erythema and swelling over mastoid process with proptosis
Fever
what could their condition be?

A

Mastoiditis
s/s of AOM too

102
Q

complications with mastoiditis

A

Subperiosteal abscess
Deep neck abscess
Septic thrombosis of lateral sinus

103
Q

cx of a mastoiditis could show what?

A

Similar to AOM
S. pneumoniae, H. flu, S. pyogenes, S. aureus
Gram negative bacilli, including Pseudomonas

104
Q

how could you diagnose mastoiditis

105
Q

tx for mastoiditis

A
  1. IV abx x 7-10 d
    - Ceftriaxane
    - Cefazolin
  2. oral abx
    - Augmentin
    - Cefdnir
  3. Myringotomy: Surgical drainage of TM
  4. Surgery if tx fails: mastoidectomy and debridement
106
Q

function of eustachian tube

A

Provides ventilation and drainage for the middle ear
Normally opens only during yawning or swallowing

107
Q

MC causes of eustachian tube dysfunction

A
  1. Viral URI MC
  2. Allergies
  3. Edema of the tubal lining
108
Q

s/s of Auditory “Eustachian” Tube Dysfunction

A
  1. Symptoms
    - Fullness in ear
    - Mild to moderate hearing impairment
    - Partially blocked tube - swallowing or yawning creates popping or crackling sound
  2. Signs
    - Retraction of TM and decreased mobility on pneumatic otoscopy or tympanometer

Lasts days to weeks following a viral infection

109
Q

tx for Auditory “Eustachian” Tube Dysfunction

A
  1. Systemic and intranasal decongestants
  2. Autoinflation by forced exhalation against closed nostrils
  3. Allergies
    - Intranasal steroids
  4. Avoid air travel and altitude change, underwater diving
110
Q

Most acute during plane descent/deep sea diving
what condition

A

barotrauma
Negative middle ear pressure tends to collapse and lock the auditory tube
Painful if tube collapses
Underwater diving more stressful to ear than flying
Descent

111
Q

Middle Ear Space is air-filled: subject to pressure changes
Unable to equalize the barometric stress on middle ear during air travel, rapid altitude change, or underwater diving

A

Barotrauma

112
Q

prevention of barotrauma

A
  1. Do not dive with conditions that can lead to ET dysfunction: viral URI
  2. Swallow, yawn, and auto inflate often during descent
  3. Systemic decongestants several hours before arrival
  4. Topical decongestants 1 hour before arrival
113
Q

tx for barotrauma

A
  1. Oral decongestants taken several hours before arrival time or topical decongestant 1 hr before
  2. Attempt autoinflation
  3. Myringotomy
  4. VT tubes if patient flies often and has severe symptoms
114
Q

underwater diving barotrauma can cause what other additional findings

A
  1. Hemotympanum
  2. Perilymphatic fistula
    - Rupture of oval or round window connecting middle/inner ear
    — Sensory hearing loss and acute vertigo
    — Emesis - due to acute labyrinthine dysfunction
115
Q

you should not go diving if you are experiencing these symptoms:

A

URI or allergies
TM perforation

116
Q

Bony overgrowths of the ear canals d/t benign tumors
Skin-covered mounds in medial ear

A

Exostoses and Osteomas

117
Q

Multiple exostoses is acquired how?

A

repeated exposure to cold water
often need surgery

118
Q

Mc causatives of neoplasia of ear canal

A
  1. Squamous cell carcinoma
  2. OE - does not resolve - biopsy
119
Q

what ear condition has high morality rate and why?

A

neoplasia of ear canal
Tumor tends to invade lymphatic of cranial base

120
Q

Adenomatous tumors originate from where?

A

ceruminous glands
More indolent

EENT (11 decks)

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